Briefing: The man who's got a whole new face

Yesterday it emerged that a farmer in his thirties in Spain who accidentally shot away the lower part of his face has become the first person to receive an entire face transplant. According to yesterday's press conference, he is already recovering well. Previously, he could only breathe and eat through tubes. Now he is expected to begin relearning how to talk, eat, smile and laugh within weeks.

Read New Scientist's guide to the intricate operation – and what challenges remain to making face transplants more common

How was the patient's face repaired?

In a 24-hour operation, a team of 30 surgeons at the Vall d'Hebron University Hospital in Barcelona, Spain, led by surgeon Joan Pere Barret, started by removing what remained of the man's face – skin, veins and arteries – leaving just his eyeballs and tongue.

The team then replaced this with practically the entire face of a dead donor, including all the skin, muscles and nerves, the entire nose, the lips, palate, all the teeth, the cheekbones and the entire lower jaw. These were grafted by microsurgery to what remained of the patient's own face, and the blood supply reconnected. In the final part of the operation, the surgeons transplanted bones and connecting nerves to the patient's own face.

But this latest is the most extensive facial graft yet, says Maria Siemionow of the Cleveland Clinic Foundation in Ohio. She came close to replacing an entire face in December 2008, but says that the Spanish team is the first to transplant both the upper and lower jaw, and both eyelids. Her team, which repaired the face of a woman who'd been shot by her husband, restored upper but not lower jawbones, and lower eyelids.

Is a whole face in any way preferable to replacing just sections because then it works as a whole?

No – and it would be risky to take away surviving parts of the face unnecessarily, in case the transplant doesn't take, says Siemionow. As a result, she says it's unlikely that a full transplant will be performed except when absolutely necessary.

How are the other patients doing?

One of those treated in France died last year, but from a bacterial infection not related to the transplant. Dinoire is still reportedly doing well five years on, despite two rejection episodes in which the immune system started to attack her transplant. Heavier immunosuppressive drugs were needed to deal with these.

Siemionow says her own patient is progressing remarkably well some 18 months after her operation. "We included very extensive rehabilitation, physical and speech therapy in her recovery programme," says Siemionow. "She's now smiling, can say all her vowels and has such normal sensation in her face that she can feel a kiss."

What are the benefits of a face transplant rather than conventional repair with skin grafts?

The major benefit is that the transplant is much more than simply a mask to cover a deformity. Because donor nerves and blood vessels plug the transplant into the patient's own tissue, the graft comes to life fully, providing function as well as cosmetic improvement.

It means people can smile, talk and eat because they can move their new lips. Likewise, they can make facial expressions and open and close their eyes. "It's not just technical coverage of missing parts, but functional restoration," says Siemionow.

What hurdles remain to be overcome now?

Siemionow says milder immunosuppression regimes are required to stop donated tissue being rejected. Because current regimes dampen the immune system, it puts recipients at abnormally high risk of infection and cancer. Siemionow says she's hoping within months to test a novel, mild regime that is based on antibodies, initially with people having kidney transplants.

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